Fluid Management in Toxic Epidermal Necrolysis
Recommended Fluid Protocol for a 70-kg Adult with 30% TBSA TEN
For a 70-kg adult with 30% TBSA involvement, initiate fluid resuscitation at approximately 2 mL/kg/% TBSA epidermal detachment over the first 24 hours, which equals approximately 4,200 mL (70 kg × 30% × 2 mL), then titrate to urine output and clinical response. 1, 2
Key Principle: TEN Requires LESS Fluid Than Burns
Fluid requirements in TEN are substantially lower than those predicted by the Parkland formula used for thermal burns. 1 The British Association of Dermatologists explicitly warns that overaggressive fluid resuscitation causes pulmonary, cutaneous, and intestinal edema. 1
The TEN-Specific Formula
- Initial fluid volume = body weight (kg) × % BSA epidermal detachment (in mL/kg/% TBSA) 1
- This formula derives from a study by Shiga and Cartotto of 21 TEN patients that documented actual fluid requirements over the first 3 days. 1, 2
- In their cohort, average crystalloid volumes were 2.2 ± 1.5 mL/kg/% TBSA on day 0, decreasing to 1.6 ± 1.1 mL/kg/% TBSA on day 1, and 1.4 ± 1.0 mL/kg/% TBSA on day 2. 2
Monitoring Endpoints
Target urine output of 0.5–1 mL/kg/hour as the primary endpoint for adequate resuscitation. 3
Essential Monitoring Parameters
- Hourly urine output measurement with target 0.5–1 mL/kg/hour 3
- Serial arterial lactate concentrations and base deficit to assess tissue perfusion 3, 2
- Daily weight measurements and strict intake/output documentation 3
- Monitor for signs of over-resuscitation: pulmonary edema, peripheral edema, intestinal edema 1
- Monitor for signs of under-resuscitation: oliguria, persistent base deficit, hypotension, confusion 1
In the Shiga and Cartotto study, urine output increased from 1.3 ± 0.9 mL/kg/hour on day 0 to 1.8 ± 1.1 mL/kg/hour by day 2, while base deficit corrected significantly, confirming adequacy of this lower fluid volume approach. 2
Critical Pitfalls to Avoid
Do not use the standard Parkland formula (4 mL/kg/% TBSA) for TEN—this will result in dangerous fluid overload. 1 The Parkland formula is designed for thermal burns and overestimates TEN requirements by approximately 50–100%. 1, 2
Do not rigidly adhere to any formula—titrate infusion rates based on clinical response and hemodynamic parameters. 3 The initial calculation provides a starting point, but individual patient response varies. 2
Do not delay transfer to a burn center for patients with >30% BSA involvement. 1, 3 These patients require specialized multidisciplinary care including intensive monitoring, expert wound management, and nutritional support. 1, 3
Practical Application for Your 70-kg Patient
Day 0 (First 24 Hours)
- Start with approximately 4,200 mL crystalloid (70 kg × 30% × 2 mL) 2
- Administer roughly 175 mL/hour as initial rate 2
- Adjust hourly based on urine output: aim for 35–70 mL/hour (0.5–1 mL/kg/hour) 3
- Check base deficit and lactate to confirm adequate tissue perfusion 2
Days 1–2
- Expect decreasing fluid requirements to approximately 1.4–1.6 mL/kg/% TBSA 2
- Continue titrating to urine output and clinical markers 3, 2
- Monitor for improving base deficit as a sign of adequate resuscitation 2
Additional Supportive Care Considerations
Maintain ambient temperature at 25–28°C in humidity-controlled environment to minimize additional insensible losses from exposed dermis. 3
Initiate early enteral nutrition providing 20–25 kcal/kg daily during the acute catabolic phase, as TEN produces a hypermetabolic state with energy expenditure approximately twice the predicted resting value. 1, 3
Provide adequate analgesia as cutaneous pain is severe, particularly at sites of epidermal detachment. 1